GABBI Armstrong will never forget going for her baby’s 10-week ultrasound and being told “I’m sorry, there is no heartbeat”.

The Botany mum has two children now but endured six miscarriages over a two-year period. On average, one in five confirmed pregnancies are thought to end in miscarriage.

Mrs Armstrong felt there were no resources to help grieving women, so she teamed up with another mum, Samantha Payne, who had also had two miscarriages, to form the Pink Elephants Support Network.

The online network aims to help women negotiate the complex emotions that come from an empty womb and a broken heart.

“You still feel pregnant, but there is no baby, there are a lot of tears and you have to know it is OK to feel devastated, it’s OK to be jealous of other pregnant women and it’s OK to feel angry and lose confidence,” she said.

The Royal Hospital for Women now offers a miscarriage care kit designed and supplied by Pink Elephants in their early pregnancy unit and they have also started information seminars for midwives and emergency department staff on how to emotionally support women through miscarriage.

“We want to help professionals to better support women going through this,” Mrs Armstrong said.

Mrs Armstrong had already travelled an emotional rollercoaster with eight rounds of IVF, 19 embryos transferred — and each ending with no pregnancy.

At age 35, Mrs Armstrong did fall pregnant naturally with son Hugh. When he was just seven months old, she fell pregnant again — and the nightmare of miscarriage began.

“There was no heartbeat, I was floored, beyond devastated,” the now 45-year-old said.

“Miscarriage really gets swept under the carpet, it’s so early, people say it’s not really a baby, it’s common, but it’s all your hopes and dreams.”

According to fertility expert Dr Gavin Sacks from IVF Australia, miscarriage rates are on the rise as women delay childbirth.

“From your mid-30s onwards, miscarriage rates become more frequent from about one in six in your early 30s to one in four at 40 and one in two at 45,” Dr Sacks said.

He said many women feel they suffer without acknowledgment.

“There’s a lot to be gained by recognising miscarriage,” he said.

Dr Sacks said there was hope for women who suffered multiple miscarriages.

“Women need to remember it is common and secondly, that it is often nature taking its course as a result of genetic abnormality but, thirdly, the chances of having a successful pregnancy the next time round are quite high, even if you have had three miscarriages, research shows you have a much higher change of success next time around,” he said.

For an engineer, Dr Michelle Oyen has spent a lot of time with placentas recently. “It’s a really weird organ, half baby, half mother. It must begin functioning at the same time as it develops. There’s nothing else like it in the body,” she says.

Oyen is committed to discovering why pregnancies go wrong. And fascinated by applying engineering principles to medical research in her post as reader in bioengineering at the University of Cambridge. “You can’t experiment on pregnant women – it’s totally unethical and impossible.” Instead, her team take high-resolution images of donated placentas to understand the geometry of blood vessels. They then use these to build 3D online models to understand how blood flows around the placenta. “We are trying to understand how cells involved in building a placenta know how to invade the right amount into a uterus,” she says. “They have to get it just right, and it’s a poorly understood process.”

Currently, one in five pregnancies are believed to end in miscarriage, and 85% of these happen in the first 12 weeks of pregnancy. Parents often have no idea why – and it can be heartbreaking for the 200,000 people (women plus partners) affected every year.

“I believe some of the problems in healthcare are some of the biggest problems in modern society,” says Oyen. “As engineers we have different tools to biologists and doctors. The more people you have approaching a problem from a different perspective, the more likely you are to understand it.”

Around the country, research collaborations are forming between universities. “There seems to be an explosion of bioengineers interested in pregnancy,” says Oyen. “But compared with other conditions it’s been understudied – from a bioengineering perspective at least.” In 2013 to 2014, miscarriage research charity Tommy’s says that the most up-to-date figures it was able to obtain indicate that just 4% of the government’s health research budget was spent on reproductive health and childbirth, with only a fraction of this going towards miscarriage research.

At the largest miscarriage research centre in Europe, hosted by the University of Birmingham, scientists and medics from Birmingham, the University of Warwick and Imperial College London are collaborating to research the causes of miscarriage, stillbirth and premature birth. Tommy’s National Centre for Miscarriage, funded by the charity, investigates potential genetic causes, including a possible link to damaged DNA in sperm, and other research avenues, such as the role of bacteria. Using clinical data from around the country, scientists hope to develop computer modelling that can predict the risk of miscarriage. “We are working to establish the role of the immune system as a prognostic factor in women with recurrent miscarriage, and incorporating these factors to predict pregnancy outcomes more accurately,” says Prof Arri Coomarasamy, director of the centre.

Currently the centre is developing clinical trial apprenticeships, based at Birmingham, for researchers and clinicians to build up relevant skills. To work in the field, you don’t necessarily need a bioengineering qualification – Coomarasamy doesn’t, although she does have three other degrees. “All kinds of engineering backgrounds – mechanical, chemical, materials – are perfectly well-suited to the work we do,” she says. “The thing about engineering is the tools we bring to the table – such as computational modelling – can be applied to any problem.”

Our research, published today in the journal Human Fertility, suggests the money being made from IVF could be subtly changing the advice doctors give.

Informed consent

Although IVF is a well-established procedure, it is not without its risks.

These include ovarian hyperstimulation syndrome, where hormone levels rise too much (causing abdominal swelling, nausea, vomiting and diarrhoea); obstetric complications such as premature delivery; and psychological distress, especially if the process fails.

Although long-term outcomes for children conceived using IVF appear to be similar to non-IVF children, questions remain about possible harmful impacts, including developmental abnormalities and cancer.

Given the financial, physical and psychological burdens of IVF, patients must be able to make informed decisions about whether to pursue these treatments in the first place, and when to stop.

A 30 year-old woman has a 40 per cent chance of a live birth after a single complete IVF cycle (so, after all viable embryos have been transferred). A 40 year-old woman, in contrast, may have a 10 per cent chance of a live birth following a complete IVF cycle.

The same 30 year-old might have a 70 per cent chance after six complete cycles, while the 40-year-old might only have a 25 per cent chance.

Success rates of IVF may appear deceptively higher if success is defined as clinical pregnancy (of just six to eight weeks), or live birth at a stage that is generally incompatible with sustained life (as early as 20 weeks or 400 grams).

Alternatively, rates may appear lower if they are reported per embryo transfer rather than per complete cycle.

To investigate this question, we conducted in-depth interviews with a range of professionals involved with ART in Australia, including obstetricians, policy advisers, researchers and counsellors.

Interviewees said financial motives were influencing ART practices in Australia, with some women offered IVF who don’t actually need it. Others are offered repeated cycles of treatment, even when they aren’t likely to succeed.

This dynamic was seen to be facilitated by the current Medicare system. The safety net protects patients by limiting the amount they have to pay out of pocket once they reach a certain threshold.

But it can also potentially encourage over-servicing and over-charging. There is no cap on the number of procedures that can be offered or the fees that can be charged.

Doctors can therefore offer additional services for higher fees without patients incurring significant additional costs. This has serious implications for the health system.

As one of the people interviewed in the study observed:

“I just think the business model and the fact that it takes advantage of Medicare, and the fact that the Medicare safety net helps spread the risk of out-of-pockets from the patient to the taxpayer is just basically being used to make some people a lot of money.”

Importantly, nobody who was interviewed suggested ART clinicians were deliberately misleading patients for their own financial benefit. The problem identified was subtler and reflected a deep ambivalence at the heart of medicine.

On the one hand, doctors are expected to be committed to their patients, research participants or the general public, and not concerned primarily with their own enrichment.

On the other hand, doctors need to earn a living and, in Australia at least, do so in a health system that supports — and even depends upon — publicly subsidised private practice.

There is no reason these interests are incompatible but their co-existence raises questions about how commercial interests may influence practice.

The commercialisation of ART raises questions not only about the motives and behaviour of clinicians, but also about how those seeking ART services should be viewed.

They could be seen as patients who are potentially highly vulnerable and to whom clinicians have a duty of care requiring them to play an active role in guiding patients in their healthcare choices even if this means some interventions are strongly discouraged.

Or they could be viewed as consumers free to choose whatever interventions they want in a healthcare marketplace, no matter how much they cost or how unlikely they are to succeed.

This idea is, of course, predicated on the assumption consumers will be provided with accurate information about risks, costs and benefits which, as many others have noted, cannot be assumed.

Although the Human Fertility study was small and does not represent the views of all professionals involved with ART in Australia, it reveals concerns about the impact of commercial interests in ART have not simply been drummed up by the media for dramatic effect.

It is time for an honest discussion about the Australian fertility industry, and about the role of money in medicine more generally.

But researchers have now identified a handful of molecules unlocking the fundamental biology of these conditions, which are present long before any symptoms arise.

Scientists have so far devoted largely unsuccessful efforts to searching for blood biomarkers from the placenta.

However, the team at the Laboratory of Premature Medicine and Immunology in San Francisco turned their attention to the placental bed, the thick mucous membrane that lines the uterus during pregnancy.

Their discovery of 30 molecules relating to gene expression will enable newly pregnant women to undergo to a simple blood test able to determine their risk.

Britain has one of the highest rates of premature birth in Europe, with roughly one in nine babies born before 37 weeks gestation.

If doctors are aware a woman is at high risk of early delivery they can monitor her more closely and potentially use hormone drugs to delay the date of birth.

While there little that can be done to prevent miscarriage, the test can help women prepare for the eventuality.

By contrast, preeclampsia can be monitored and better managed the earlier it is detected.

Around three per cent of pregnant women suffer the condition where blood pressure is raised to levels that threaten both mother and child.

The only cure is to deliver the baby, meaning doctors can sometimes be forced to induce dangerously premature births.

Tim Child, assistant professor of obstetrics and gynaecology at Oxford University, said the new research was “very promising” and described the statistical relationship between the discovery of blood biomarkers in patients in the study and their subsequent complications as “very, very strong”.

Presented at the American Association of Reproductive Medicine annual congress in Texas, the four combined studies involved 160 births.

Searching for microRNA in blood immune cells, the team were able to predict miscarriage and late preeclampsia with around 90 per cent accuracy and premature birth before 34 weeks with around 89 per cent accuracy.

Premature birth between 34 and 38 weeks was predicted with 92 per cent accuracy.

Professor Simon Fishel, an IVF pioneer and founder of Care Fertility, said a warning highlighting blood flow problems in the placental bed, potential treatments include blood thinning drugs such as heparin.

“Specialist obstetricians have means to help manage such disorders and early recognition of these complications is vital.

“Further support and evidence for this biomarker could indeed be an important tool in the management of these high risk pregnancies.”

He added that to be ‘forewarned is forearmed’ when dealing with pregnancy complications.

Specialist obstetricians have means to help manage such disorders and early recognition of these complications is vital.

Further support and evidence for this biomarker could indeed be an important tool in the management of these high risk pregnancies.’

“Our combined analysis supports the idea that the Great Obstetrical Syndromes have a common biological origin early in the first trimester that can be detected throughout the first trimester using peripheral blood cell microRNA,” the researchers said.

Roughly one in four pregnancies end in miscarriage, although this reduces to one in six pregnancies where the mother knows she is pregnant.

A blood test in the first 12 weeks of pregnancy could indicate a risk of miscarriage or premature birth, early research suggests.

US doctors believe they have found molecules in the blood that can be linked to serious birth complications, months before symptoms are apparent.

The findings could help doctors take steps to avoid premature birth.

But experts warned against overstating the findings, citing the “small and preliminary” nature of the research.

In the UK, one in five pregnancies ends in miscarriage, while Britain has one of the highest rates of premature birth in Europe.

The proposed blood test screens for molecules called microRNA, which are found in blood cells in the placental bed – a thick membrane that lines the uterus during pregnancy.

Predicting problems

The team, from the Laboratory for Reproductive Medicine and Immunology in San Francisco, assessed the microRNA cells’ ability to predict premature birth, pre-eclampsia, and miscarriage during the first 12 weeks of pregnancy.

In total, they looked at 160 births – over a series of four published studies.

The results predicted miscarriage and late pre-eclampsia with about 90% accuracy and premature birth before 34 weeks with about 89% accuracy.

Pre-eclampsia is a serious condition where abnormally high blood pressure and other problems develop during pregnancy.

It affects up to 10% of all first-time pregnancies and often leads to premature birth.

Unlike that of miscarriage, the risk of pre-eclampsia and premature birth can be managed by medical intervention.

The study authors said the test could possibly be used in combination with other established screening tests.

‘Root cause’

Daniel Brison, honorary professor of clinical embryology and stem cell biology at the University of Manchester, said the study was “exciting looking” in a much needed area.

But he added: “Although the results might seem exciting and cutting edge, there is unfortunately a high risk of them being wrong.

“We’d need larger follow-up studies to be sure whether these results are valid.”

Tim Child, associate professor at the University of Oxford and medical director of Oxford Fertility, echoed his concerns but described the research as important.

“Pre-eclampsia, premature birth and miscarriage are significant issues all around the world, so any research is important,” he told BBC News, stressing that “while the number [of cases studies] is very limited, the statistical relationship between the test and the complication is very high.”

He added that he hoped ongoing research would help doctors understand “the root cause” of placental disease.

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About Dr Gavin Sacks

Gavin completed his medical training at both Cambridge and Oxford Universities, including a degree in experimental psychology. He then trained further in clinical medicine in Leeds, Glasgow, London and Sydney.

At the same time, scientists were making ground-breaking advances in IVF technology. Gavin wanted to be a part of this medical revolution that was bringing real hope to infertile couples and is now one of Australia's leading IVF specialists.